<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <meta name="viewport" content="width=device-width, initial-scale=1.0">
    <meta http-equiv="X-UA-Compatible" content="ie=edge">
    <title>Document</title>
    <link rel="stylesheet" href="bootstrap/css/bootstrap.css">
    <style>
            ul{display:block;margin:0;padding:0;list-style:none;}
    li{display:block;margin:0;padding:0;list-style: none;}
    img{border:0;}
        .place{height:40px; background:url(images/righttop.gif) repeat-x;}
    .place span{line-height:40px; font-weight:bold;float:left; margin-left:12px;}
    .placeul li{float:left; line-height:40px; padding-left:7px; padding-right:12px; background:url(images/rlist.gif) no-repeat right;}
    .placeul li:last-child{background:none;}
        </style>
        </head>
        <body>
        <div class="place"> <span>位置：</span>
          <ul class="placeul">
            <li><a href="index.html">首页</a></li>
            <li>信息列表</li>
          </ul>
        </div>
        
        <div class="panel panel-default">
              <div class="panel-heading">
                    <h3 class="panel-title">单据结算</h3>
              </div>
              <div class="panel-body">
                   
                   <div class="panel panel-info" style="border:0px;">
                         <div class="panel-heading">
                               <h3 class="panel-title">老人信息</h3>
                         </div>
                         <div class="panel-body">
                               
                               <table class="table table-hover table-bordered">
                                   
                                   <tbody>
                                       <tr>
                                           <td class=" text-right">老人姓名:</td>
                                           <td >廖俊智</td>
                                           <td class=" text-right">老人编号:</td>
                                           <td class="">20181000001</td>
                                           <td class="text-right">性别:</td>
                                           <td c>男</td>
                                           <td class="text-right">年龄</td>
                                           <td >41</td>
                                       </tr>
                                       <tr>
                                            <td class=" text-right">入住日期:</td>
                                            <td >2018-07-25</td>
                                            <td class=" text-right">状态:</td>
                                            <td >在院</td>
                                            <td class=" text-right">居住类型:</td>
                                            <td  colspan="3">长住</td>
                                        </tr>
                                        
                                       <tr>
                                            <td class=" text-right">护理级别:</td>
                                            <td colspan="2">介护</td>
                                            <td class=" text-right">餐饮类型:</td>
                                            <td colspan="4">普食</td>
                                        
                                        </tr>
                                        <tr>
                                                <td class=" text-right">月费用:</td>
                                                <td colspan="7">床位费：850.00 元/月  /  护理费：700.00 元/月  /  餐饮费：600.00 元/月  /  管理费：0.00 元/月  /  其他：0.00 元/月  /  （合计：2150元） [使用价格体系：2018年价格体系]</td>
                                                                                           
                                        </tr>
                                        <tr>
                                                <td class=" text-right">账号余额:</td>
                                                <td colspan="7"> 10204.52 元 </td>
                                                                                           
                                        </tr>
                                   </tbody>
                               </table>
                               
                         </div>
                   </div>
                   <div class="panel panel-info" style="border:0px;">
                        <div class="panel-heading">
                              <h3 class="panel-title">结算单信息</h3>
                        </div>
                        <div class="panel-body">
                             <div class="container">
                                
                                <form action="" method="POST" role="form" class="form-horizontal">
                                    <legend>单据类型：<span>账户充值</span></legend>
                                
                                    <div class="form-group">
                                        <label for="">结算时间:</label>
                                        
                                        <input type="date" name="xxx" id="inputxxx" class="form-control" value="" required="required" title="">
                                        
                                    </div>
                                    <div class="form-group">
                                            <label for="">支付方式:</label>
                                            
                                           
                                           <select name="" id="input" class="form-control" required="required">
                                               <option value="">现金</option>
                                               <option value="">支付宝</option>
                                               <option value="">微信</option>
                                           </select>
                                           
                                        </div>
                                        <div class="form-group">
                                                <label for="">应收金额:</label>
                                                <label for="" style="color:red; font-size: 20px;">2150元</label>                                    
                                            </div>
                                    
                                            <div class="form-group">
                                                    <label for="">实收金额:</label>
                                                    
                                                    <input type="text" name="" id="input" class="form-control" value="" required="required" pattern="" title="">
                                                    
                                                </div>
                                                <div class="form-group">
                                                        <label for="">备注:</label>
                                                        
                                                        <textarea name="" id="input" class="form-control" rows="3" required="required"></textarea>
                                                        

                                                    </div>
                                    <button type="submit" class="btn btn-inverse  ">结算</button>
                                </form>
                                

                             </div>
                        </div>
                  </div>
                   
              </div>
        </div>
        
</body>
</html>